Payment Allowance Limits for Medicare Part B Drugs
Effective January 1, 2006 through March 31, 2006
Note 1: Payment allowance limits subject to the ASP methodology are based on 3Q05 ASP data. Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category.  These determinations shall be made by the local Medicare contractor processing the claim.
HCPCS Code	Short Description	HCPCS Code Dosage	Payment Limit	Vaccine AWP%	Vaccine Limit	Infusion AWP%	DME Infusion Limit	Blood AWP%	Blood Limit	Notes
90371	Hep b ig, im	1 ML	$118.235
90375	Rabies ig, im/sc	150 IU	$64.905
90376	Rabies ig, heat treated	150 IU	$68.914
90385	Rh ig, minidose, im	50 MCG	$6.613
90396	Varicella-zoster ig, im	125 UNITS	$110.411
90585	Bcg vaccine, percut	50 MG	$118.161
90586	Bcg vaccine, intravesical	1 EACH	$115.087
90632	Hep a vaccine, adult im	1 ML	$42.184
90633	Hep a vacc, ped/adol, 2 dose	1 ML	$22.644
90634	Hep a vacc, ped/adol, 3 dose	3 EACH	$22.652
90645	Hib vaccine, hboc, im	1 EACH	$21.520
90647	Hib vaccine, prp-omp, im	0.5 ML	$21.520
90648	Hib vaccine, prp-t, im	0.5 ML	$21.782
90655	Flu Vaccine	0.25 ML	$14.678
90656	Flu vaccine no preserv 3 & >	0.50 ML	$15.818	95%	$15.818
90657	Flu vaccine, 6-35 mo, im	0.25 ML	$6.028	95%	$6.028
90658	Flu vaccine age 3 & over, im	0.5 ML	$12.056	95%	$12.056
90675	Rabies vaccine, im	1 ML	$147.203
90691	Typhoid vaccine, im	0.5 ML	$37.519
90700	Dtap vaccine, < 7 yrs, im	0.5 ML	$22.642
90702	Dt vaccine < 7, im	0.5 ML	$17.500
90703	Tetanus vaccine, im	0.5 ML	$21.424
90704	Mumps vaccine, sc	0.5 ML	$19.145
90705	Measles vaccine, sc	0.5 ML	$14.493
90706	Rubella vaccine, sc	0.5 ML	$16.165
90707	Mmr vaccine, sc	0.5 ML	$38.505
90713	Poliovirus, ipv, sc/im	0.5 ML	$25.009
90716	Chicken pox vaccine, sc	0.5 ML	$67.342
90717	Yellow fever vaccine, sc	0.5 ML	$59.460
90721	Dtap/hib vaccine, im	1 EACH	$41.724
90732	Pneumococcal vaccine	0.5 ML	$24.571	95%	$24.571
90733	Meningococcal vaccine, sc	0.5 ML	$86.100
90735	Encephalitis vaccine, sc	1 ML	$88.127
90740	Hepb vacc, ill pat 3 dose im	40 MCG	$113.914	95%	$113.914
90743	Hep b vacc, adol, 2 dose, im	10 MCG	$67.928	95%	$67.928
90744	Hepb vacc ped/adol 3 dose im	1 DOSE	$68.381	95%	$68.381
90746	Hep b vaccine, adult, im	1 EACH	$56.957	95%	$56.957
90747	Hepb vacc, ill pat 4 dose im	40 MCG	$113.914	95%	$113.914
J0128	Abarelix injection	10 MG	$67.394
J0130	Abciximab injection	10 MG	$525.993
J0132	Acetylcysteine injection	100 MG	$1.733
J0133	Acyclovir injection	5 MG	$0.025
J0135	Adalimumab injection	20 MG	$301.766
J0150	Injection adenosine 6 MG	6 MG	$32.568
J0152	Adenosine injection	30 MG	$70.298
J0170	Adrenalin epinephrin inject	1 ML	$0.599
J0180	Agalsidase beta injection	1 MG	$127.200
J0205	Alglucerase injection	10 UNITS	$39.220
J0207	AMIfostine	500 MG	$442.331
J0210	Methyldopate hcl injection	250 MG	$9.986
J0215	Alefacept	0.5 MG	$26.506
J0256	Alpha 1 proteinase inhibitor	10 MG	$3.233
J0270	Alprostadil for injection	1.25 MCG	$1.823
J0275	Alprostadil urethral suppos	125 MCG	$21.661
J0278	AMIkacin sulfate injection	50 MG	$1.304
J0280	AMInophyllin 250 MG inj	250 MG	$0.395
J0282	AMIodarone HCl	30 MG	$0.325
J0285	Amphotericin B	50 MG	$7.618			95%	$10.280
J0287	Amphotericin b lipid complex	10 MG	$11.272			95%	$21.850
J0288	Ampho b cholesteryl sulfate	10 MG	$12.000			95%	$15.200
J0289	Amphotericin b liposome inj	10 MG	$19.031			95%	$35.800
J0290	Ampicillin 500 MG inj	500 MG	$2.458
J0295	Ampicillin sodium per 1.5 gm	1.5 GM	$6.504
J0300	Amobarbital 125 MG inj	125 MG	$2.427
J0330	Succinycholine chloride inj	20 MG	$0.137
J0350	Injection anistreplase 30 u	30 UNITS	$2,268.460
J0360	Hydralazine hcl injection	20 MG	$6.088
J0365	Aprotonin, 10,000 kiu	10000 KIU	$2.333
J0456	Azithromycin	500 MG	$24.887
J0460	Atropine sulfate injection	0.3 MG	$0.398
J0470	Dimecaprol injection	100 MG	$21.802
J0475	Baclofen 10 MG injection	10 MG	$191.118			95%	$215.180
J0476	Baclofen intrathecal trial	50 MCG	$71.002			95%	$79.800
J0480	Basiliximab	20 MG	$1,410.893
J0500	Dicyclomine injection	20 MG	$15.956
J0515	Inj benztropine mesylate	1 MG	$3.873
J0530	Penicillin g benzathine inj	600000 UNITS	$13.189
J0540	Penicillin g benzathine inj	1200000 UNITS	$25.584
J0550	Penicillin g benzathine inj	2400000 UNITS	$33.479
J0560	Penicillin g benzathine inj	600000 UNITS	$19.545
J0570	Penicillin g benzathine inj	1200000 UNITS	$33.837
J0580	Penicillin g benzathine inj	2400000 UNITS	$65.719
J0583	Bivalirudin	1 MG	$1.623
J0585	Botulinum toxin a per unit	1 UNIT	$4.906
J0587	Botulinum toxin type B	100 UNITS	$7.821
J0592	Buprenorphine hydrochloride	0.1 MG	$0.751
J0595	Butorphanol tartrate 1 mg	1 MG	$0.767
J0600	Edetate calcium disodium inj	1 ML	$39.934
J0610	Calcium gluconate injection	10 ML	$0.404
J0630	Calcitonin salmon injection	400 UNITS	$37.810
J0636	Inj calcitriol per 0.1 mcg	0.1 MCG	$0.705
J0637	Caspofungin acetate	5 MG	$32.462
J0640	Leucovorin calcium injection	50 MG	$1.277
J0670	Inj mepivacaine HCL/10 ml	10 ML	$1.309
J0690	Cefazolin sodium injection	500 MG	$1.383
J0692	Cefepime HCl for injection	500 MG	$7.554
J0694	Cefoxitin sodium injection	1 GM	$7.143
J0696	Ceftriaxone sodium injection	250 MG	$5.432
J0697	Sterile cefuroxime injection	750 MG	$4.123
J0698	Cefotaxime sodium injection	1 GM	$4.348
J0702	Betamethasone acet&sod phosp	3 MG	$4.983
J0704	Betamethasone sod phosp/4 MG	4 MG	$0.907
J0706	Caffeine citrate injection	5 MG	$3.368
J0713	Inj ceftazidime per 500 mg	500 MG	$3.969
J0715	Ceftizoxime sodium / 500 MG	500 MG	$3.570
J0720	Chloramphenicol sodium injec	1 GM	$10.178
J0725	Chorionic gonadotropin/1000u	1000 UNITS	$3.722
J0740	Cidofovir injection	375 MG	$740.000
J0743	Cilastatin sodium injection	250 MG	$12.633
J0744	Ciprofloxacin iv	200 MG	$8.443
J0745	Inj codeine phosphate /30 MG	30 MG	$0.716
J0760	Colchicine injection	1 MG	$4.446
J0770	Colistimethate sodium inj	150 MG	$24.199
J0780	Prochlorperazine injection	10 MG	$3.251
J0795	Corticorelin ovine triflutal	1 EA	$4.063
J0800	Corticotropin injection	40 UNITS	$107.755
J0835	Inj cosyntropin per 0.25 MG	0.25 MG	$65.943
J0850	Cytomegalovirus imm IV /vial	1 ML	$721.415
J0878	Daptomycin injection	1 MG	$0.294
J0881	Darbepoetin alfa, non-esrd	1 MCG	$2.989
J0882	Darbepoetin alfa, esrd use	1 MCG	$2.989
J0885	Epoetin alfa, non-esrd	1000 UNITS	$9.027
J0886	Epoetin alfa, esrd	1000 UNITS	$9.570
J0895	DeferoxAMIne mesylate inj	500 MG	$15.204			95%	$15.630
J0970	Estradiol valerate injection	40 MG	$30.979
J1000	Depo-estradiol cypionate inj	5 MG	$5.292
J1020	Methylprednisolone 20 MG inj	20 MG	$2.807
J1030	Methylprednisolone 40 MG inj	40 MG	$5.270
J1040	Methylprednisolone 80 MG inj	80 MG	$9.283
J1051	Medroxyprogesterone inj	50 MG	$5.153
J1056	MA/EC contraceptiveinjection	5 MG	$22.885
J1060	Testosterone cypionate 1 ML	1 ML	$4.142
J1070	Testosterone cypionat 100 MG	100 MG	$5.156
J1080	Testosterone cypionat 200 MG	200 MG	$12.310
J1100	Dexamethasone sodium phos	1 MG	$0.121
J1110	Inj dihydroergotAMIne mesylt	1 MG	$25.341
J1120	AcetazolAMId sodium injectio	500 MG	$14.905
J1160	Digoxin injection	0.5 MG	$3.974
J1162	Digoxin immune fab (ovine)	PER VIAL	$540.910
J1165	Phenytoin sodium injection	50 MG	$0.663
J1170	Hydromorphone injection	4 MG	$1.605			95%	$1.490
J1180	Dyphylline inj	500 MG	$8.045
J1190	Dexrazoxane HCl injection	250 MG	$186.715
J1200	DiphenhydrAMIne hcl injectio	50 MG	$0.760
J1205	Chlorothiazide sodium inj	500 MG	$10.197
J1212	Dimethyl sulfoxide 50% 50 ML	50 ML	$42.368
J1230	Methadone injection	10 MG	$3.245			95%	$0.750
J1240	Dimenhydrinate injection	50 MG	$3.830
J1245	Dipyridamole injection	10 MG	$1.680
J1250	Inj dobutAMIne HCL/250 mg	250 MG	$5.024			95%	$4.740
J1260	Dolasetron mesylate	10 MG	$6.368
J1265	DopAMIne injection	40 MG	$0.709
J1270	Injection, doxercalciferol	1 MCG	$2.685
J1320	AMItriptyline injection	20 MG	$2.237
J1325	Epoprostenol injection	0.5 MG	$13.269			95%	$12.640
J1327	Eptifibatide injection	5 MG	$13.139
J1335	Ertapenem injection	500 MG	$22.254
J1364	Erythro lactobionate /500 MG	500 MG	$5.128
J1380	Estradiol valerate 10 MG inj	10 MG	$11.929
J1390	Estradiol valerate 20 MG inj	20 MG	$15.490
J1410	Inj estrogen conjugate 25 MG	25 MG	$56.668
J1430	EthanolAMIne oleate 100 mg	100 MG	$83.139
J1435	Injection estrone per 1 MG	1 MG	$0.138
J1436	Etidronate disodium inj	300 MG	$71.407
J1438	Etanercept injection	25 MG	$154.228
J1440	Filgrastim 300 mcg injection	300 MCG	$176.963
J1441	Filgrastim 480 mcg injection	480 MCG	$279.354
J1450	Fluconazole	200 MG	$14.042
J1451	Fomepizole, 15 mg	15 MG	$11.885
J1452	Intraocular Fomivirsen na	1.65 MG	$212.000
J1455	Foscarnet sodium injection	1000 MG	$9.942			95%	$13.070
J1457	Gallium nitrate injection	1 MG	$1.247
J1460	Gamma globulin 1 CC inj	1 ML	$11.633
J1470	Gamma globulin 2 CC inj	2 ML	$23.266
J1480	Gamma globulin 3 CC inj	3 ML	$34.882
J1490	Gamma globulin 4 CC inj	4 ML	$46.531
J1500	Gamma globulin 5 CC inj	5 ML	$58.164
J1510	Gamma globulin 6 CC inj	6 ML	$69.864
J1520	Gamma globulin 7 CC inj	7 ML	$81.350
J1530	Gamma globulin 8 CC inj	8 ML	$93.062
J1540	Gamma globulin 9 CC inj	9 ML	$104.797
J1550